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First, the patient, second the patient, third the patient, fourth the patient, fifth the patient, and then maybe comes science. We first do everything for the patient; science can wait, research can wait.— Béla Schick (1877–1967)
The upside of medical progress needs no emphasis. The downside, however, does. Hence, this editorial.
In 1989, as I was entering my fourth decade as a full-time medical educator, something important happened to me. For the first time in my life, I began waking up at night desperately short of breath. The difficulty would resolve shortly after I sat upright. At first, I didn't think much about it. But when the episodes grew in frequency and duration, I became concerned.
Naturally, the first thing I thought of was some sort of heart disease. So I obtained a chest film, an electrocardiogram, and some routine blood and urine tests. All gave normal results. Then, with recurrent pulmonary embolism in mind, I underwent a ventilation/perfusion (V/Q) lung scan. It, too, showed no abnormality. Next, I sought consultation from one of Houston's best internists. He had no clear explanation for my complaints but suggested an arrhythmia or epileptic equivalent as possible causes. Consequently, I wore a Holter monitor for 2 days and had an electroencephalogram, both of which yielded normal findings. At that point, I feared going to bed each night and wondered what the future held for me.
Finally, because no physical basis for my complaints had been identified, I decided to see a respected psychiatrist. Shortly after our session began, he asked me how things were going at work. About 5 minutes into my answer, he interrupted me and said, “Herb, I know what your problem is. You're mourning the death of bedside medicine.”
His diagnosis came as a total surprise but made perfect sense. It also worked wonders, bringing my dreaded nightly wake-ups to an abrupt end while enabling me to wake up to what had been gnawing at me for a long time.
In 1929, the year I was born, house calls were part of a doctor's daily routine. I remember as a youngster that our family physician would come to my sickbed—day or night—to examine and comfort me. After he had determined the nature of my illness, he would explain his diagnosis and treatment plan to my mother. Then, if his schedule permitted, he would stay to have a bite to eat with my parents. On Sundays, he would frequently drop by to have some fried chicken or to play cards with my dad. We adored him, and he adored us.
As the years rolled on, the practice of making house calls gradually waned, and by the time I entered medical school in 1950 it had largely disappeared. Nevertheless, ties between patients and their doctors remained strong until the early 1970s, when high-tech medicine began replacing the high-touch, bedside-type medicine that I grew up with and loved.
For nearly 4 decades now, I have watched with sorrow the progressive demise of bedside medicine. Admittedly, the advent of ultrasonography, echocardiography, computed tomography (CT), and magnetic resonance imaging has enabled us to establish diagnoses with speed, accuracy, and safety never before imagined. At the same time, however, overreliance on these technologic marvels has crippled physicians' use of the mind and the 5 sensory faculties to make diagnoses. Jumping from the patient's chief complaint to a host of tests and procedures has become virtually routine. And when that approach fails, the physician typically orders more tests and seeks numerous consultations.
This new way of practicing medicine has made the skilled clinical diagnostician a vanishing species, a true “dinosaur.” It has also taken most of the fun and challenge out of medicine. It has depersonalized the patient–doctor relationship and has essentially eliminated the individuality of patient care. I call this malady of practice “technologic tenesmus”: the uncontrollable urge to rely on the lastest medical gadgetry for diagnoses.
Technologic tenesmus is insidious in onset, highlycontagious, and rapidly addictive. It endangers all practitioners of medicine, particularly those who are ill-trained, ill-informed, and looking for shortcuts. It is especially virulent among those who lack self-confidence or fear litigation. Unaware of their affliction, the victims become tools of the laboratory—shackled to the routine of using advanced technology to formulate rather than to substantiate their clinical impressions.
The following cases show 3 common ways in which technologic tenesmus can lead to inappropriate patient care.
Technologic tenesmus is closely related to another paralyzing illness of our profession. That illness is “hyposkillia”: a deficiency of clinical skills.1 By definition, those afflicted are ill-equipped to render good patient care. Yet, residency training programs across the country continue to graduate growing numbers of these hyposkilliacs: physicians who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess the information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly. Moreover, they rarely spend enough time to know their patients “through and through.”2 And because they are quick to treat, hyposkilliacs learn nothing about the natural history of disease.
These hyposkilliacs, however, do become proficient at a number of things. They learn to order all kinds of tests and procedures, but they don't always know when to order or how to interpret them. They also learn to play the numbers game, treating a number or some other type of test result rather than the patient to whom the number or test result pertains. And, by repeatedly using so many elaborate tests and procedures, these doctors inevitably and unwittingly acquire a laboratory-oriented rather than a patient-oriented mindset.
Why do we allow such deficiencies to develop, persist, and grow? I believe that it's because nearly all of today's teachers of medicine received their training after the early 1970s—the time when modern medical technology began to burgeon. High-tech medicine is all they've ever seen, all they know, and, therefore, all they know to teach. Through no fault of their own, they have no real sense of high-touch medicine: medicine based on a carefully constructed medical history coupled with a pertinent physical examination and critical assessment of the information obtained therefrom. In the practice of high-touch medicine, if any studies are deemed necessary, the simpler ones are ordered first.
One other point is important. In bypassing or curtailing the history-taking and physical examination, the high-tech approach weakens the patient–doctor bond, or prevents it from ever forming. By contrast, the high-touch approach—the apotheosis of Oslerian medicine—ensures that we treat the patient, not the disease.
Magnifying the problem is the fact that American medical schools have always valued research over teaching. This stance had little detrimental effect on medical education for most of the past century. But now, the ever-increasing emphasis on technology, the shrinking of government funding of medical services, and the devastating impact of managed care have delivered a serious blow to clinical teaching. Medical schools are so strapped for money these days that they force the clinical faculty to spend progressively more time caring for patients who can pay their bills and progressively less time caring for medical students and house officers. Consequently, trainees are left to fend for themselves in the quest for competency, unaware of how much better their lot could be and should be.
At present, house officers learn clinical medicine primarily from each other, rather than from veteran clinicians. Students, in turn, learn clinical medicine primarily from house officers who are several years their senior but are not necessarily more knowledgeable or competent. This arrangement had merit many years ago when residencies, in contrast to internships, were reserved for the elite. In those days, acceptance into a residency provided no guarantee of completing it. And since most training programs had a pyramid structure, attrition always occurred: only the best residents remained. From that group, 1 resident ultimately became the chief resident, who also served as chief assistant to the departmental chair.
Today, residency positions are much more numerous and much easier to obtain. And because the pyramid structure is largely a relic of the past, the relative number of weak residents has risen. In many ways, therefore, we now have a see-one, do-one, teach-one system that fosters mediocrity, stifles individuality, promotes incompetence, and permits—if not encourages—dishonesty.
Even more disturbing to me now, after a half century as a full-time medical educator, is the mandate in 2003 from the Accreditation Council for Graduate Medical Education (ACGME) that imposes work-hour limits across all training programs, regardless of specialty. Acting to promote patient safety, the ACGME sided with the widely held—but still disputed—notion that sleep deprivation and physical fatigue in physicians lead to harmful medical errors. Accordingly, house officers now must leave the hospital by 1 PM on their post-call days, are not allowed to average more than 80 hours of work per week, and typically take off 1 day a week.
In my view, these work-hour limits have made a bad situation much worse. They rob trainees of the opportunity to learn the natural history of disease. They encourage laziness. They disrupt continuity of patient care. And they create extra work for an already overworked teaching faculty who now must do what the “off-duty” house officers should be doing.
Hence, from its roots as a patient-centered, learning-oriented experience, medical education has evolved into a laboratory-centered, algorithm-oriented, technology-driven, computer-dependent, Internet-based, “treat first, diagnose later” training system. In other words, we are exchanging sleep-deprived healers for a cadre of wide-awake hyposkilliacs.
Is that what patients want? Is that what patients need? Is that what patients deserve? I don't think so. But I do think that unless medical education undergoes substantial reform, things will only get worse. Look at it this way: When you get sick, would you rather have a tired, competent doctor or a well-rested, incompetent doctor?
Today's trainees often tell me that I'm old-fashioned. I wonder. Is it because old-fashioned doctors
Or is it because old-fashioned doctors consider it an honor and a privilege to practice medicine?
Whatever the reason(s), I am proud to be old-fashioned. And I believe that if more doctors today practiced medicine the old-fashioned way, our profession would regain some of the nobility and respect it once enjoyed.
Looking back on my professional career, I see enormous progress in our ability to detect and treat disease. But along with that progress, we have sacrificed to a large extent the very core of doctoring—humanism. We need to recapture the Oslerian spirit and strive diligently to promote and preserve the human element in medicine. To do that, we must have doctors who demonstrate commitment, compassion, candor, and common sense; doctors who can look at, listen to, and talk with their patients; doctors who understand and believe that medicine is a calling, not a business; and doctors who always put their patients first.
Address for reprints: Herbert L. Fred, MD, MACP, 8181 Fannin St., Suite 316, Houston, TX 77054